Communication About Chronic Pain and Opioids in Primary Care

Impact on Patient and Physician Visit Experience

Stephen G. Henry; Robert A. Bell; Joshua J. Fenton; Richard L. Kravitz

Disclosures

Pain. 2018;159(2):371-379. 

In This Article

Abstract and Introduction

Abstract

Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient–physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables—patient–physician disagreement and patient requests for opioid dose increases—were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient–physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.

Introduction

Chronic pain is among the most common complaints in primary care.[5,10] Patients and physicians report that clinic visits involving discussions about chronic pain are often difficult or unsatisfying,[25,27,40] particularly when visits involve discussions about opioid analgesics.[9,26] Physicians report difficulty communicating with "narcotic-seeking" patients who request higher opioid doses,[3,30] whereas patients report that physicians do not appreciate their plight or take their pain seriously.[40]

Identifying patient–physician communication patterns associated with patient and physician visit experience is an important step towards characterizing best practices for communicating about chronic pain and opioids. However, most research on communication about pain and visit experience relies on participant recall and is thus subject to the limitations of human memory and emotion.[14,35] Ideally, such research should include observational data from actual patient–physician interactions, which is the gold standard for this line of investigation.[16] As a result of overreliance on recall, we know little about the extent to which actual communication about pain during visits (as opposed to recollections) is associated with patients' and physicians' experiences of care.

Understanding these relationships has assumed greater urgency because physicians find themselves caught between 2 policy developments. First, health insurers, including Medicare, are increasingly basing reimbursement on patients' ratings of their health care experience.[2] In the context of chronic pain, some physicians complain that this approach produces pressure to prescribe opioids to high-risk patients to avoid conflict and maintain high patient experience scores.[24,43] Second, growing evidence of serious opioid-related harms (without corresponding evidence of clinical effectiveness) has prompted recent dramatic shifts in clinical guidelines that discourage the routine use of opioids to treat chronic pain.[6] These shifts may make negotiations around opioids even more difficult as physicians recommend that patients on long-term opioids taper down to lower, safer doses.

In this study, we analyzed video-recorded primary care clinic visits involving patients on long-term opioids for chronic musculoskeletal pain, and then systematically coded communication during these visits to identify associations among patient characteristics and attitudes related to pain, communication during visits, patient experience, and physician-reported visit difficulty. Our analysis focused on discussions of pain and opioid prescribing. Findings from this study can be used to inform design of communication-based interventions and training programs aimed at improving patient–physician communication about chronic pain and opioids, while also promoting safe opioid prescribing.

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